Provider Demographics
NPI:1457136897
Name:YANG, MICHELLE JIA JIA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JIA JIA
Last Name:YANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 LAKEPORT BLVD # 276
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5412
Mailing Address - Country:US
Mailing Address - Phone:530-828-5749
Mailing Address - Fax:
Practice Address - Street 1:7000B S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8131
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program